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"Every single mental health practitioner involved with the deceased reported she was difficult to engage and evasive, and did not always tell the truth," she said.

Ms Vickers did not accept that the woman should have been under constant supervision because it could have made her mental condition worse.

"The systems in place have to allow for the fact that being constantly under supervision for some patients may be the catalyst, which prevents their ability to recover at all, and so survive in the community."

* Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14 or the Suicide Call Back Service on 1300 659 467.